Polypharmacy in the Elderly <ul><li>Rosemary D. Laird, MD </li></ul><ul><li>Assistant Professor of Medicine </li></ul><ul>...
Polypharmacy in the Elderly <ul><li>Overview of Polypharmacy </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><l...
The Brown Bag <ul><li>Verapamil 300mg po qday </li></ul><ul><li>Lasix 20mg po qday </li></ul><ul><li>Digoxin 0.25mg po qda...
Polypharmacy in the Elderly By definition…. <ul><li>Polypharmacy means &quot;many drugs“. </li></ul><ul><li>The use of mo...
Polypharmacy in the Elderly WHY? <ul><li>The elderly use more drugs because illness is more common in older persons. </li>...
Polypharmacy in the Elderly How Bad Can It Be? <ul><li>Elderly = 12% of population but </li></ul><ul><li> 32% of prescrip...
Polypharmacy in the Elderly What’s the big deal? <ul><li>Polypharmacy leads to: </li></ul><ul><ul><li>More adverse drug re...
Adverse Drug Reactions <ul><li>The most consistent risk factor for adverse drug reactions is: </li></ul><ul><li>number of ...
 
Pharmacokinetics and Aging <ul><li>“ What the Body Does to the Drug ” </li></ul><ul><ul><li>Absorption </li></ul></ul><ul...
Pharmacokinetics and Aging <ul><li>Absorption : </li></ul><ul><ul><li>Age-related gastrointestinal tract and skin change...
Pharmacokinetics and Aging <ul><li>Distribution : </li></ul><ul><ul><li>Important Age-Related Changes: </li></ul></ul><u...
Pharmacokinetics and Aging <ul><li>Metabolism: </li></ul><ul><ul><li>Though liver function tests are unchanged with age, ...
Pharmacokinetics and Aging <ul><li>Renal Excretion: </li></ul><ul><ul><li>Age-related decreased renal blood flow and GF...
Pharmacokinetics and Aging <ul><li>Thus, serum creatinine may appear normal even when significant renal impairment exists...
Pharmacodynamics and Aging <ul><li>“ What the Drug Does to the Body ” </li></ul><ul><li>Generally, lower drug doses are r...
(Potentially)Inappropriate Medications for Older Adults * <ul><li>Propoxephene </li></ul><ul><li>Diphenhydramine </li></ul...
(Potentially)Inappropriate Medications for Older Adults <ul><li>Diphenhydramine </li></ul><ul><ul><li>should generally be...
(Potentially)Inappropriate Medications for Older Adults
(Potentially)Inappropriate Medications for Older Adults
Polypharmacy in the Elderly <ul><li>Overview </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><li>Medications an...
Polypharmacy and Non-adherence <ul><li>Non-adherence </li></ul><ul><li>Is a two-way street! </li></ul><ul><li>Physician ...
Polypharmacy and Non-adherence <ul><li>Factors contributing to Polypharmacy </li></ul><ul><ul><li>Underreporting symptoms...
Polypharmacy and Non-adherence <ul><li>Strongest predictor is number of medications </li></ul><ul><ul><li>Rates estimated...
Factors contributing to Non-adherence <ul><li>Large number of medications </li></ul><ul><li>Expensive medications </li>...
Polypharmacy in the Elderly <ul><li>Overview of Polypharmacy </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><l...
Polypharmacy and the Primary Care Provider <ul><li>Annual Brown Bag </li></ul><ul><li>At least yearly, and more often if...
Vitamin and Herbal Use in Older Adults <ul><li>Highly prevalent among older adults </li></ul><ul><ul><li>77% in Johnson an...
What to do with the Brown Bag full of bottles? <ul><li>Document and determine indication </li></ul><ul><li>Prioritize </l...
 
Polypharmacy in the making…. Why are you taking this? <ul><li>I don’t know…the doctor told me to…… </li></ul><ul><ul><li>D...
Polypharmacy in the making… <ul><li>Discontinuing unnecessary medications is one of the most important aspects of decreasi...
Polypharmacy in the Making… <ul><li>Drug reactions in the elderly often produce effects that simulate the conventional ima...
Polypharmacy in the Making… <ul><li>Avoid treating adverse reactions/side effects of drug with more drugs! </li></ul><ul><...
Polypharmacy in the Making… <ul><li>Drugs most frequently associated with adverse reactions in the elderly: </li></ul><ul>...
Polypharmacy in the Elderly <ul><li>Overview of Polypharmacy </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><l...
Prescribing Pearls <ul><li>Use single daily dose regimens </li></ul><ul><li>Limit the use of PRN medications </li></ul><ul...
Prescribing Pearls <ul><li>Attempt to prescribe a drug that will treat more than one existing problem </li></ul><ul><ul><...
Patient Education <ul><li>Use one pharmacist/pharmacy </li></ul><ul><li>Use your PCP as intended…avoid seeing multiple phy...
Avoiding Polypharmacy <ul><li>Simple </li></ul><ul><ul><li>Use least frequent dosing needed </li></ul></ul><ul><ul><li>Tie...
 
Ways to Decrease Drug Costs <ul><li>Generics ok </li></ul><ul><li>Change dosing regimen, e.g. one-a-day may be more expen...
The Brown Bag <ul><li>HTN, MI 15 yrs ago, arthritis, GERD, BPH with nocturia </li></ul><ul><li>Verapamil 300mg po qday </l...
The Brown Bag <ul><li>HTN, MI 15 yrs ago, arthritis, GERD, BPH with nocturia </li></ul><ul><li>Verapamil 300mg po qday </l...
The Brown Bag <ul><li>HTN, MI 15 yrs ago, arthritis, GERD, BPH with nocturia </li></ul><ul><li>MOM 30 cc po qhs prn consti...
The New Brown Bag <ul><li>Beta-blocker qday </li></ul><ul><ul><li>Atenolol 25-100 mg </li></ul></ul><ul><li>?Alpha-blocker...
References <ul><li>Geriatrics at your Fingertips </li></ul><ul><ul><li>http://www.americangeriatrics.org/products/gayf2.sh...
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Polyphar

Published on: Mar 4, 2016
Published in: Education      Health & Medicine      
Source: www.slideshare.net


Transcripts - Polyphar

  • 1. Polypharmacy in the Elderly <ul><li>Rosemary D. Laird, MD </li></ul><ul><li>Assistant Professor of Medicine </li></ul><ul><li>University of Kansas Medical Center </li></ul><ul><li>Center on Aging </li></ul>
  • 2. Polypharmacy in the Elderly <ul><li>Overview of Polypharmacy </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><li>Medications and the Elderly </li></ul></ul><ul><li>Polypharmacy and Non-adherence </li></ul><ul><li>The role of the PCP </li></ul><ul><li>Prescribing Pearls </li></ul>
  • 3. The Brown Bag <ul><li>Verapamil 300mg po qday </li></ul><ul><li>Lasix 20mg po qday </li></ul><ul><li>Digoxin 0.25mg po qday </li></ul><ul><li>KCL 20mEq po bid </li></ul><ul><li>Proscar 5mg po qday </li></ul><ul><li>MOM 30 cc po qhs prn constipation </li></ul><ul><li>Aleve 200mg 2-4 tablets po prn arthritis </li></ul><ul><li>TUMS extra-strength 0-8 per day prn GERD </li></ul><ul><li>** was there more?? </li></ul>
  • 4. Polypharmacy in the Elderly By definition…. <ul><li>Polypharmacy means &quot;many drugs“. </li></ul><ul><li>The use of more medication than is clinically indicated or warranted. </li></ul><ul><ul><li>5 or more drugs </li></ul></ul><ul><ul><li>7 or more drugs </li></ul></ul>
  • 5. Polypharmacy in the Elderly WHY? <ul><li>The elderly use more drugs because illness is more common in older persons. </li></ul><ul><ul><li>Cardiovascular disease </li></ul></ul><ul><ul><li>Arthritis </li></ul></ul><ul><ul><li>Gastrointestinal disorders </li></ul></ul><ul><ul><li>Bladder dysfunction </li></ul></ul>
  • 6. Polypharmacy in the Elderly How Bad Can It Be? <ul><li>Elderly = 12% of population but </li></ul><ul><li> 32% of prescriptions </li></ul><ul><li>Average use for persons  65 </li></ul><ul><ul><li>2 to 6 prescription drugs + </li></ul></ul><ul><ul><li>1 to 3.4 over-the-counter medicine </li></ul></ul><ul><li>Average American senior spends $670/year for pharmaceuticals. </li></ul>
  • 7. Polypharmacy in the Elderly What’s the big deal? <ul><li>Polypharmacy leads to: </li></ul><ul><ul><li>More adverse drug reactions </li></ul></ul><ul><ul><li>Decreased adherence to drug regimens </li></ul></ul><ul><ul><li>Patient outcomes </li></ul></ul><ul><ul><li>Poor quality of life </li></ul></ul><ul><ul><li>High rate of symptomatology </li></ul></ul><ul><ul><li>(Unnecessary) drug expense </li></ul></ul>
  • 8. Adverse Drug Reactions <ul><li>The most consistent risk factor for adverse drug reactions is: </li></ul><ul><li>number of drugs being taken </li></ul><ul><ul><li>Risk rises exponentially as the number of drugs increases. </li></ul></ul>
  • 10. Pharmacokinetics and Aging <ul><li>“ What the Body Does to the Drug ” </li></ul><ul><ul><li>Absorption </li></ul></ul><ul><ul><li>Distribution </li></ul></ul><ul><ul><li>Metabolism </li></ul></ul><ul><ul><li>Excretion </li></ul></ul>
  • 11. Pharmacokinetics and Aging <ul><li>Absorption : </li></ul><ul><ul><li>Age-related gastrointestinal tract and skin changes seem to be of minor clinical significance for medication usage. </li></ul></ul>
  • 12. Pharmacokinetics and Aging <ul><li>Distribution : </li></ul><ul><ul><li>Important Age-Related Changes: </li></ul></ul><ul><ul><ul><li>Decrease in Lean Body Mass and TBW </li></ul></ul></ul><ul><ul><ul><li>Increased percentage Body Fat </li></ul></ul></ul><ul><ul><li>Increase in volume of distribution for lipophilic drugs, such as sedatives that penetrate CNS. </li></ul></ul><ul><ul><ul><li>Protein Binding changes are of modest significance for most drugs, especially at steady-state. </li></ul></ul></ul>
  • 13. Pharmacokinetics and Aging <ul><li>Metabolism: </li></ul><ul><ul><li>Though liver function tests are unchanged with age, there is some overall decline in metabolic capacity. </li></ul></ul><ul><ul><li>Decreased liver mass and hepatic blood flow </li></ul></ul><ul><ul><ul><li>Highly variable, no good estimation algorithm </li></ul></ul></ul><ul><ul><ul><li>Minimal clinical manifestations </li></ul></ul></ul>
  • 14. Pharmacokinetics and Aging <ul><li>Renal Excretion: </li></ul><ul><ul><li>Age-related decreased renal blood flow and GFR is well-established. </li></ul></ul><ul><ul><li>Decreased lean body mass leads to decreased creatinine production. </li></ul></ul>
  • 15. Pharmacokinetics and Aging <ul><li>Thus, serum creatinine may appear normal even when significant renal impairment exists. </li></ul><ul><li>Cr clearance=(140-age)(IBW)/creatinine(72) </li></ul><ul><ul><li>(multiply by 0.85 for women) </li></ul></ul><ul><ul><li>Example: “70kg” 75 year old man </li></ul></ul><ul><ul><li>Cr Clearance= (140-75)(70)/1.0(72)=63 </li></ul></ul>
  • 16. Pharmacodynamics and Aging <ul><li>“ What the Drug Does to the Body ” </li></ul><ul><li>Generally, lower drug doses are required to achieve the same effect with advancing age. </li></ul><ul><ul><li>Receptor numbers, affinity, or post-receptor cellular effects may change. </li></ul></ul><ul><ul><li>Changes in homeostatic mechanisms can increase or decrease drug sensitivity. </li></ul></ul>
  • 17. (Potentially)Inappropriate Medications for Older Adults * <ul><li>Propoxephene </li></ul><ul><li>Diphenhydramine </li></ul><ul><li>Amitryptiline </li></ul><ul><li>Alprazolam </li></ul><ul><li>Diazepam </li></ul><ul><li>* Beers, MH et al. Arch Intern Med 151:1825,1991. </li></ul>
  • 18. (Potentially)Inappropriate Medications for Older Adults <ul><li>Diphenhydramine </li></ul><ul><ul><li>should generally be avoided in older adults </li></ul></ul><ul><ul><li>Dry mouth, confusion, urinary retention, constipation </li></ul></ul><ul><ul><li>source of in-hospital morbidity/delirium </li></ul></ul><ul><ul><li>is in many OTC products for sleep/URI/allergy </li></ul></ul><ul><li>Digoxin </li></ul><ul><ul><li>can cause anorexia, confusion even at therapeutic drug levels </li></ul></ul><ul><ul><li>Renal excretion can change over time as age-related renal function declines. </li></ul></ul><ul><ul><li>0.125mg/day most often adequate </li></ul></ul>
  • 19. (Potentially)Inappropriate Medications for Older Adults
  • 20. (Potentially)Inappropriate Medications for Older Adults
  • 21. Polypharmacy in the Elderly <ul><li>Overview </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><li>Medications and the Elderly </li></ul></ul><ul><li>Polypharmacy and Non-adherence </li></ul><ul><li>The Role of the PCP </li></ul><ul><li>Prescribing Pearls </li></ul>
  • 22. Polypharmacy and Non-adherence <ul><li>Non-adherence </li></ul><ul><li>Is a two-way street! </li></ul><ul><li>Physician factors </li></ul><ul><li>Patient factors </li></ul>
  • 23. Polypharmacy and Non-adherence <ul><li>Factors contributing to Polypharmacy </li></ul><ul><ul><li>Underreporting symptoms </li></ul></ul><ul><ul><li>Use of multiple providers </li></ul></ul><ul><ul><li>Use of others’ medications </li></ul></ul><ul><ul><li>Limited time for discussion, diagnostics </li></ul></ul><ul><ul><li>Limited knowledge of geriatric pharmacology </li></ul></ul><ul><ul><li>The power of inertia </li></ul></ul>
  • 24. Polypharmacy and Non-adherence <ul><li>Strongest predictor is number of medications </li></ul><ul><ul><li>Rates estimated at 25-50% </li></ul></ul><ul><ul><li>Intentional about 75% of the time </li></ul></ul><ul><ul><ul><li>Changes in regimen made by patients to increase convenience, reduce adverse effects, or decrease refill expense </li></ul></ul></ul>
  • 25. Factors contributing to Non-adherence <ul><li>Large number of medications </li></ul><ul><li>Expensive medications </li></ul><ul><li>Complex or frequently changing schedule </li></ul><ul><li>Adverse reactions </li></ul><ul><li>Confusion about brand name/trade name </li></ul><ul><li>Difficult-to-open containers </li></ul><ul><li>Rectal, vaginal, SQ modes of administration </li></ul><ul><li>Limited patient understanding </li></ul>
  • 26. Polypharmacy in the Elderly <ul><li>Overview of Polypharmacy </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><li>Medications and the Elderly </li></ul></ul><ul><li>Polypharmacy and Non-adherence </li></ul><ul><li>The Role of the PCP </li></ul><ul><li>Prescribing Pearls </li></ul>
  • 27. Polypharmacy and the Primary Care Provider <ul><li>Annual Brown Bag </li></ul><ul><li>At least yearly, and more often if indicated, ask elderly patients to bring in all medications they have at home. </li></ul><ul><ul><li>Prescription </li></ul></ul><ul><ul><li>Over-the-counter </li></ul></ul><ul><ul><li>Vitamins supplements </li></ul></ul><ul><ul><li>Herbal preparations </li></ul></ul>
  • 28. Vitamin and Herbal Use in Older Adults <ul><li>Highly prevalent among older adults </li></ul><ul><ul><li>77% in Johnson and Wyandotte county community dwelling elderly </li></ul></ul><ul><li>Generally not reported to the physician </li></ul><ul><li>Some serious drug interactions possible: </li></ul><ul><ul><li>Warfarin, gingko biloba, vitamin E </li></ul></ul>
  • 29. What to do with the Brown Bag full of bottles? <ul><li>Document and determine indication </li></ul><ul><li>Prioritize </li></ul><ul><ul><ul><li>Vital vs. optional </li></ul></ul></ul><ul><ul><ul><li>Cure vs. relieve symptom </li></ul></ul></ul><ul><li>Discuss with patient, caregiver </li></ul><ul><li>Plan for medication reduction </li></ul><ul><ul><ul><li>Vital vs. optional </li></ul></ul></ul><ul><ul><ul><li>Cure vs. relieve symptom </li></ul></ul></ul>
  • 31. Polypharmacy in the making…. Why are you taking this? <ul><li>I don’t know…the doctor told me to…… </li></ul><ul><ul><li>Digoxin </li></ul></ul><ul><ul><li>Allopurinol </li></ul></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Anxiolytics </li></ul></ul>
  • 32. Polypharmacy in the making… <ul><li>Discontinuing unnecessary medications is one of the most important aspects of decreasing polypharmacy </li></ul><ul><li>Drugs without indications should be stopped! </li></ul>
  • 33. Polypharmacy in the Making… <ul><li>Drug reactions in the elderly often produce effects that simulate the conventional image of growing old: </li></ul><ul><li>unsteadiness drowsiness </li></ul><ul><li>dizziness falls </li></ul><ul><li>confusion depression </li></ul><ul><li>nervousness incontinence </li></ul><ul><li>fatigue malaise </li></ul><ul><li>insomnia </li></ul>
  • 34. Polypharmacy in the Making… <ul><li>Avoid treating adverse reactions/side effects of drug with more drugs! </li></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><li>Dizziness from anti-hypertensive treated with meclizine </li></ul></ul><ul><ul><li>Edema from a calcium-channel blocker treated with furosemide and KCL </li></ul></ul>
  • 35. Polypharmacy in the Making… <ul><li>Drugs most frequently associated with adverse reactions in the elderly: </li></ul><ul><ul><li>psychotropic drugs-benzodiazepines </li></ul></ul><ul><ul><li>anti-hypertensive agents </li></ul></ul><ul><ul><li>diuretics </li></ul></ul><ul><ul><li>digoxin </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>corticosteroids </li></ul></ul><ul><ul><li>warfarin </li></ul></ul><ul><ul><li>theophylline </li></ul></ul>
  • 36. Polypharmacy in the Elderly <ul><li>Overview of Polypharmacy </li></ul><ul><ul><li>The Brown Bag </li></ul></ul><ul><ul><li>Medications and the Elderly </li></ul></ul><ul><li>Polypharmacy and Non-adherence </li></ul><ul><li>The Role of the PCP </li></ul><ul><li>Prescribing Pearls </li></ul>
  • 37. Prescribing Pearls <ul><li>Use single daily dose regimens </li></ul><ul><li>Limit the use of PRN medications </li></ul><ul><li>Consider all new medicines as a therapeutic trial </li></ul><ul><li>Discontinue a drug if it is ineffective or intolerable adverse effects occur </li></ul><ul><li>Provide legible written instructions </li></ul><ul><li>Instruct caregivers as needed </li></ul>
  • 38. Prescribing Pearls <ul><li>Attempt to prescribe a drug that will treat more than one existing problem </li></ul><ul><ul><li>Examples: </li></ul></ul><ul><ul><li>calcium channel blocker or beta blocker to treat both hypertension and angina pectoris </li></ul></ul><ul><ul><li>ACE-inhibitor to treat both hypertension, heart failure, and or for renal protection in diabetes </li></ul></ul><ul><ul><li>Alpha-blocker to treat both hypertension and prostatism </li></ul></ul>
  • 39. Patient Education <ul><li>Use one pharmacist/pharmacy </li></ul><ul><li>Use your PCP as intended…avoid seeing multiple physicians </li></ul><ul><li>Do not use medications from others </li></ul><ul><li>Report symptoms </li></ul><ul><li>All medicines, even over-the-counter, have adverse effects </li></ul><ul><li>Report all products used </li></ul>
  • 40. Avoiding Polypharmacy <ul><li>Simple </li></ul><ul><ul><li>Use least frequent dosing needed </li></ul></ul><ul><ul><li>Tie to scheduled daily activities, meals, sleep/wake </li></ul></ul><ul><li>Support </li></ul><ul><ul><li>Educate </li></ul></ul><ul><ul><li>Medication Flowsheet </li></ul></ul><ul><ul><li>Encourage use of one pharmacist </li></ul></ul><ul><ul><li>Enlist family, friends as needed </li></ul></ul><ul><ul><li>Medication organization equipment </li></ul></ul><ul><li>Survey </li></ul><ul><ul><li>Periodic review </li></ul></ul>
  • 42. Ways to Decrease Drug Costs <ul><li>Generics ok </li></ul><ul><li>Change dosing regimen, e.g. one-a-day may be more expensive </li></ul><ul><li>Older drugs, e.g. beta blockers, diuretics, acetaminophen </li></ul><ul><li>Double duty drugs, e.g. beta and alpha blockers, ACE-inhibitors </li></ul><ul><li>Avoid non-regulated products </li></ul>
  • 43. The Brown Bag <ul><li>HTN, MI 15 yrs ago, arthritis, GERD, BPH with nocturia </li></ul><ul><li>Verapamil 300mg po qday </li></ul><ul><li>Lasix 20mg po qday </li></ul><ul><li>Digoxin 0.25mg po qday </li></ul><ul><li>KCL 20mEq po bid </li></ul><ul><li>Proscar 5mg po qday </li></ul><ul><li>MOM 30 cc po qhs prn constipation </li></ul><ul><li>Aleve 200mg 2-4 tablets po prn arthritis </li></ul><ul><li>TUMS extra-strength 0-8 per day prn GERD </li></ul><ul><li>** was there more?? </li></ul>
  • 44. The Brown Bag <ul><li>HTN, MI 15 yrs ago, arthritis, GERD, BPH with nocturia </li></ul><ul><li>Verapamil 300mg po qday </li></ul><ul><ul><li>Can change to beta blocker or alpha blocker(?) </li></ul></ul><ul><li>Lasix 20mg po qday </li></ul><ul><li>Digoxin 0.25mg po qday </li></ul><ul><li>KCL 20mEq po bid </li></ul><ul><ul><li>D/C </li></ul></ul><ul><li>Proscar 5mg po qday </li></ul><ul><ul><li>D/C </li></ul></ul>
  • 45. The Brown Bag <ul><li>HTN, MI 15 yrs ago, arthritis, GERD, BPH with nocturia </li></ul><ul><li>MOM 30 cc po qhs prn constipation </li></ul><ul><ul><li>May not need </li></ul></ul><ul><li>Aleve 200mg 2-4 tablets po prn arthritis </li></ul><ul><ul><li>Tylenol 1gram qid or Arthritis formula BID </li></ul></ul><ul><li>TUMS extra-strength 0-8 per day prn GERD </li></ul><ul><ul><li>May not need after d/c NSAID </li></ul></ul><ul><li>** was there more?? </li></ul>
  • 46. The New Brown Bag <ul><li>Beta-blocker qday </li></ul><ul><ul><li>Atenolol 25-100 mg </li></ul></ul><ul><li>?Alpha-blocker </li></ul><ul><ul><li>titrate to nocturia, BP </li></ul></ul><ul><li>Tylenol Arthritis 2 tabs bid </li></ul>
  • 47. References <ul><li>Geriatrics at your Fingertips </li></ul><ul><ul><li>http://www.americangeriatrics.org/products/gayf2.shtml </li></ul></ul><ul><li>Essentials of Clinical Geriatrics, 4 th Edition. Kane, Ouslander, Abrass, Eds. McGraw-Hill. </li></ul>

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